Section I: Weight, Diet and Exercise

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Section I: Weight, Diet and Exercise Module of 2003 Mail Survey On Diabetes

Label Type Description
I1 Question How would you describe your weight right now? Do you consider yourself: (Mark one.) .D Uncertain, can't say
I2 Question Do you have a target or goal for what you would like your weight to be?
I3 Question What is it?
I4 Question During the past 12 months, have you tried to lose weight?
I5 Question In the past 2 weeks, have you walked for exercise?
I6 Question If yes:
I7 Question In the past 2 weeks, have you done moderately strenuous household chores, like scrubbing and vacuuming?
I8 Question If yes:
I9 Question In the past 2 weeks, have you done moderately strenuous household chores like mowing or raking the lawn, shoveling snow, or working in the garden? (qxi9)
I10 Question If yes:
I11 Question In the past 2 weeks, have you danced?
I12 Question If yes:
I13 Question In the past 2 weeks, have you gone bowling? (qxi13)
I14 Question If yes:
I15 Question In the past 2 weeks, have you participated in any regular exercise program such as stretching or strengthening exercise, swimming, or any other regular exercise program?
I16 Question If yes:
I17 Question In the past 2 weeks, have you participated in any vigorous exercise, like running/jogging, biking, tennis, aerobic dance, or hiking?
I18 Question If yes:
I19 Question Think about the walking you do outside your home. During the last week, about how many city blocks or their equivalents did you walk?
I20 Question What is your usual pace? (Mark one.)
I21 Question In the past two weeks, do you feel that you exercised about the right amount, less, or more than you would like? (Mark one.)
I22A Question Which of the following are problems for you in getting enough exercise? (Circle one answer for each line.) It takes too much effort.
I22B Question You don't believe it is useful.
I22C Question You don't like to do it.
I22D Question You have a health problem that makes it difficult.
I22E Question You're too old.
I22F Question There's no good place to exercise.
I22G Question It makes your diabetes more difficult to control.
I22H Question It's hard to find the time.
I22I Question You have no one to exercise with.
I23A Question How often do you have any problem with keeping your balance: (Circle one answer for each line.) When you are walking on a level surface
I23B Question When you are dressing while standing
I23C Question When you are standing with your eyes closed, such as in the shower
I23D Question When you are walking down stairs
I24 Question Do you ever feel dizzy or light-headed after standing up?
I25 Question Have you fallen in the past 12 months? Falling includes falling on the ground or an uncontrolled fall into a chair, bed, or sofa.
I26 Question If yes, how many times have you fallen in the past 12 months?